Tobacco use and tobacco services in California substance use treatment programs

Reducing tobacco use in substance use treatment: The California tobacco free initiative

BACKGROUND

People in substance use disorder (SUD) treatment have a smoking prevalence that is five times higher than the national average. California funded the Tobacco Free for Recovery Initiative, designed to support programs in implementing tobacco-free grounds and increasing smoking cessation services. In the first cohort of the initiative (2018-2020) client smoking prevalence decreased from 54.2% to 26.6%. The current study examined whether similar findings would be replicated with a later cohort of programs (2020-2022).

METHOD

Cross-sectional survey data were collected from clients in 11 residential SUD treatment programs at baseline (n = 185) and at post intervention (n = 227). Multivariate logistic regression assessed change over time in smoking prevalence, tobacco use behaviors, and receipt of cessation services across the two timepoints.

RESULTS

Client smoking prevalence decreased from 60.3 % to 40.5 % (Adjusted Odds Ratio [AOR] = 0.46, 95 % CI = 0.27, 0.78; p = 0.004). Current smokers and those who quit while in treatment reported an increase in nicotine replacement therapy (NRT)/pharmacotherapy from baseline to post intervention (31.9 % vs 45.6 %; AOR = 2.22, 95 % CI = 1.08, 4.58; p = 0.031).

CONCLUSIONS

Like the first cohort, the Tobacco Free for Recovery initiative was associated with decreased client smoking prevalence and an increase in NRT/pharmacotherapy. These findings strengthen the evidence that similar initiatives may be effective in reducing smoking prevalence among people in SUD treatment.

Policy and Practice Changes Associated with a Tobacco-Free Initiative in Residential Substance Use Disorder Treatment

A California-sponsored, 18-month, tobacco-free intervention in residential substance use disorder (SUD) programs was associated with increases in tobacco-free grounds and tobacco-related client services. The current study examined whether positive results would be replicated in 11 programs participating subsequently. Program directors (N = 11) completed surveys of tobacco-related policies pre- and post-intervention. Pre- (n = 163) and post-intervention (n = 128) cross-sectional staff surveys examined tobacco-related training, beliefs, practices, smoking policy, and smoking status. Directors reported increases in tobacco-free grounds (from 3 to 8 programs), tobacco-related staff training (1 to 10 programs), tobacco cessation staff services (1 to 9 programs) and nicotine replacement therapy (NRT) provision (6 to 10 programs). At post-intervention, staff were more likely to report smoke-free workplaces (p = 0.008), positive beliefs about treating tobacco use (p = 0.017) and less likely to report current smoking (p = 0.003). Clinical staff were more likely to report tobacco-related training receipt (p = 0.001), program-level NRT provision (p = 0.009) and conducting tobacco-related client services (p < 0.0001) post-intervention. Findings of increases in tobacco-free grounds and tobacco cessation client services corroborated prior results. These and the additional finding of decreases in staff smoking strengthen evidence that initiatives supporting tobacco-free policies can be successfully implemented in SUD treatment.

Effect of age of tobacco initiation and number of failed quit attempts on maintenance of tobacco abstinence

BACKGROUND

The decision to make a quit attempt is the first step toward the tobacco cessation process. It is well established in the literature that if someone does not take tobacco till the age of 21 years then his chances of remaining tobacco-free for life are higher than his counterparts who start tobacco at early developmental ages.

METHODOLOGY AND TOOLS

The present study was conducted among 400 university undergraduate students. A cross-sectional survey design was used, multi-stage sampling was done, and four colleges were selected via random sampling. The motivation to quit tobacco, tobacco craving, and maintenance of tobacco abstinence was assessed via contemplation ladder, tobacco craving questionnaire Short Form, and smoking abstinence questionnaire. To validate subjective data, a urine cotinine test was performed.

RESULTS

The age of tobacco initiation significantly impacts intentions to quit tobacco and tobacco craving levels. The number of unsuccessful quit attempts was also significantly associated with the maintenance of tobacco abstinence. The failed quit attempts play a vital role in altering tobacco cravings and make the withdrawals more complicated to handle for recent tobacco quitters.

Gambling, tobacco use, and health among individuals in substance use disorder treatment

BACKGROUND AND OBJECTIVES

Gambling is highly comorbid with disordered use of tobacco and other drugs, and may increase relapse risk among substance use disorder (SUD) patients. We investigated associations between gambling and tobacco use behaviors among SUD patients to inform clinical care.

METHODS

Patients (N = 651, 170 female) from 25 residential SUD treatment programs in California completed surveys about tobacco use, health, and gambling. Using multivariate regression, we examined associations between gambling, tobacco use behaviors, and mental and physical health.

RESULTS

Past-year gamblers were more likely than non-gamblers to be current smokers (adjusted odds ratio [AOR] = 1.44, 95% confidence interval [CI] = 1.03, 2.01). Smokers who gambled had higher mean Heaviness of Smoking Index (HSI) scores (mean difference = +0.32, 95% CI = 0.04, 0.60), and more often reported smokeless tobacco use (AOR = 1.73, 95% CI = 1.16, 2.58), compared to non-gambling smokers. Past-year problem gamblers were more likely than all others (non-gamblers and non-problem gamblers) to be current smokers (AOR = 1.44, 95% CI = 1.08, 1.90) and to report high psychosocial stress (AOR = 1.87, 95% CI = 1.34, 2.61). Smokers with problem gambling also had higher HSI scores (mean difference = +0.54, 95% CI = 0.14, 0.95) compared to smokers without problem gambling.

DISCUSSION AND CONCLUSIONS

Gambling and problem gambling were associated with tobacco use and heavier smoking. SUD patients with gambling comorbidity may be heavier smokers and may need concurrent treatment for tobacco use and problem gambling.

SCIENTIFIC SIGNIFICANCE

This study provides novel data regarding gambling and tobacco use behaviors among SUD patients.

Smoking Behavior and Wellness among Individuals in Substance Use Disorder Treatment

Tobacco-related morbidity and mortality disproportionately affect people with substance use disorders (SUD). Encouraging overall wellness may support tobacco use cessation. We investigated relationships between wellness (health status, physical activity, sugar-sweetened beverage (SSB) consumption), cigarette smoking, and smoking cessation among SUD treatment patients to inform clinical care. Cross-sectional surveys were conducted with 395 patients in 20 California residential SUD programs. Using multivariate regression, we examined associations between smoking status and wellness. Among smokers, we examined associations between lifetime smoking exposure, cessation behaviors and attitudes, and wellness. Compared to nonsmokers (n = 121), smokers (n = 274) reported more SSB consumption, poorer physical health, and more respiratory symptoms. Among smokers, SSB consumption and respiratory symptoms increased per ten pack-years of smoking. Smokers with respiratory symptoms reported higher motivation to quit and more use of nicotine replacement therapy (NRT). Smokers with more days of poor mental health reported lower motivation to quit. Overall, cigarette smoking was associated with other health-risk behaviors among SUD treatment patients. Respiratory symptoms may increase, and poor mental health may decrease, SUD patients' intent to quit smoking. To reduce chronic disease risk among SUD patients, treatment programs should consider promoting overall wellness concurrently with smoking cessation.

A cluster-randomized trial of a brief multi-component intervention to improve tobacco outcomes in substance use treatment

BACKGROUND

Smoking prevalence is high among people in substance use disorder (SUD) treatment, and program interventions to address smoking are often complex and lengthy. This cluster-randomized trial tested whether a brief multi-component intervention impacted tobacco outcomes among staff and clients.

METHODS

Seven SUD treatment programs were randomly assigned to the multi-component intervention or to waitlist control. The 6-month intervention included a leadership motivation assessment, program incentives, 4 staff training sessions and a leadership learning community session. Survey data were collected from staff and clients at pre- and post-intervention. Outcomes were first compared across condition (intervention vs waitlist control), and then examined pre- to post-intervention with condition collapsed.

RESULTS

Staff in the intervention (n = 48) and control conditions (n = 26) did not differ at post-intervention on smoking prevalence, self-efficacy to help clients quit, or practices used to help clients quit smoking. Intervention clients (n = 113) did not differ from controls (n = 61) in smoking prevalence or receipt of tobacco services. Pre-post comparisons collapsed across condition showed a decrease in client and staff smoking prevalence, which could not be attributed to the intervention, and a decrease in client receipt of cessation medication.

CONCLUSION

The brief multi-component intervention did not support changes in smoking prevalence or in tobacco-related services received by clients. Other intervention features are needed to reduce smoking among SUD clients.

TRIAL REGISTRATION

Randomization occurred at the program level and outcomes measured are program-level measures. Accordingly, the trial is not registered.

Addressing nutrition and physical activity in substance use disorder treatment: Client reports from a wellness-oriented, tobacco-free policy intervention

Introduction

Interest in wellness interventions in substance use disorder (SUD) treatment is growing although evidence remains limited. This study evaluated nutrition, physical activity, nutrition and physical activity counseling, and relationships of counseling with wellness behavior before and after a wellness-oriented, tobacco-free policy intervention in 17 residential SUD programs.

Methods

Clients completed cross-sectional surveys reporting sugar-sweetened beverage consumption, physical activity, and receipt of nutrition and physical activity counseling before (n= 434) and after (n = 422) an 18-month intervention. Multivariable regression models assessed pre-post-intervention differences in these variables and examined associations of nutrition counseling with sugar-sweetened beverage consumption and physical activity counseling with physical activity.

Results

Post-intervention clients were 83% more likely than pre-intervention clients to report nutrition counseling (p = 0.024). There were no pre-post- differences for other variables. Past week sugar-sweetened beverage consumption was 22% lower among clients reporting nutrition counseling than for those who did not (p = 0.008) and this association did not vary by time (pre/post). There was a significant interaction of physical activity counseling receipt by time on past week physical activity (p = 0.008). Pre-intervention clients reporting physical activity counseling had 22% higher physical activity than those who did not; post-intervention clients reporting physical activity counseling had 47% higher physical activity.

Conclusion

A wellness policy intervention was associated with increased nutrition counseling. Nutrition counseling predicted lower sugar-sweetened beverage consumption. Physical activity counseling predicted higher physical activity, an association that was greater post-intervention. Adding wellness components to tobacco-related interventions may promote health among SUD clients.

Comparing client and staff reports on tobacco-related knowledge, attitudes, beliefs and services provided in substance use treatment

INTRODUCTION

Smoking is highly prevalent in substance use disorder (SUD) programs, but few studies have explored the tobacco-related attitudes of staff and clients in the same program. The aim of this study was to compare staff and client reports on 10 tobacco-related items and associate them with tobacco measures implemented in the programs.

METHODS

A cross-sectional survey was conducted in 18 residential SUD programs from 2019 to 2020. Overall, 534 clients and 183 clinical staff self-reported their tobacco use, knowledge, attitudes, beliefs, and practices/services regarding smoking cessation. Ten comparable items were asked of both clients and staff. Differences in their responses were tested using bivariate analyses. We examine the association between selected tobacco-related items on making a quit attempt and planning to quit in the next 30 days.

RESULTS

In all, 63.7% of clients were current cigarette users versus 22.9% of staff. About half of clinicians (49.4%) said they had the skills to help patients quit smoking, while only 34.0% of clients thought their clinicians had these skills (p=0.003). About 28.4% of staff reported encouraging their patients to use nicotine replacement treatment (NRT), and 23.4% of patients said they had been encouraged to use these products. Client reports of planning a quit attempt were positively correlated with whether both staff and clients reported that the use of NRT was encouraged (clients: r=0.645 p=0.004; staff: r=0.524 p=0.025).

CONCLUSIONS

A low level of tobacco-related services was provided by staff and received by clients. In programs where smokers were encouraged to use NRT, a higher percentage of smokers planned a quit attempt. Tobacco-related training among staff, and communication about tobacco use with clients, should be improved to make tobacco services more visible and accessible in SUD treatment.

A randomized controlled trial of contingency management for smoking cessation in substance use treatment patients

Background/Objective

Contingency management (CM) is one of the most effective interventions for smokers with substance use disorder (SUD), and no empirical assessment of its long-term efficacy has been conducted so far in a real-world context. The objectives were: (1) examine the additive effectiveness of CM on cognitive-behavioral treatment (CBT) for smoking cessation, and (2) examine the relationship between smoking cessation and substance use abstinence.

Method

A total of 80 participants (75.8% males; M_age = 45.31; SD = 9.64) were assigned to two smoking cessation treatments: CBT or CBT+CM. A set of generalized estimating equations were conducted to examine the effect of treatment condition on smoking outcomes, as well as the effect of smoking status on substance abstinence.

Results

Adding CM to CBT for smoking cessation improved tobacco abstinence rates at the end-of-treatment (p = .049). Tobacco abstinence rates declined over time (p = .012), but no significant effects of treatment condition were observed across follow-ups (p = .260). Smoking cessation was not significantly related to substance abstinence (p ≥ .488).

Conclusions

CM facilitates early abstinence in smokers with SUD, although effects subside after treatment termination. The lack of association between smoking abstinence and substance use suggests no jeopardizing effects as a result of quitting smoking.

Integration of smoking cessation into standard treatment for patients receiving opioid agonist therapy who are smoking tobacco: protocol for a randomised controlled trial (ATLAS4LAR)

BACKGROUND

About 85% of patients receiving opioid agonist therapy (OAT) for opioid dependence are smoking tobacco. Although smoke-related pulmonary diseases are significant contributors to morbidity and mortality, few smoking cessation interventions are evaluated within this group, and few OAT patients are offered smoking cessation as an integrated part of their addiction treatment. This study protocol describes an integrated smoking cessation intervention aimed at patients receiving OAT and smoking tobacco.

METHODS

This is a multicentre, randomised controlled clinical trial that will recruit 266 daily tobacco smoking patients receiving OAT in OAT outpatient clinics in Bergen and Stavanger, Norway. The patients randomised for the intervention arm will be offered smoking cessation therapy consisting of weekly brief behavioural interventions and prescription-free nicotine replacement products. In the control arm, patients will receive standard care without any added interventions related to smoking cessation. The smoking cessation intervention includes psychoeducational techniques with components from motivational interviewing, and nicotine replacement products such as nicotine lozenges, patches, and chewing gum. The duration of the intervention is 16 weeks, with the option of extending it by a further 8 weeks. The main outcomes are measured at 16 weeks after initiation of the intervention, and sustained effects are evaluated 1 year after intervention initiation. The primary outcome is smoking cessation verified by carbon monoxide (CO) levels or at least a 50% reduction in the number of cigarettes smoked. Secondary outcomes are changes in psychological well-being, biochemical inflammation markers, changes in physical health, quality of life, and fatigue.

DISCUSSION

Integration of other treatments to standard OAT care improves adherence and completion rates providing another rationale for integrated smoking cessation treatment. Thus, if integrated smoking cessation treatment is superior to standard care, this trial provides important information on further scale-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05290025. Registered on 22 March 2022.

Pre-implementation Assessment of Tobacco Cessation Interventions in Substance Use Disorder Residential Programs in California

BACKGROUND

Across the United States, substance use disorder (SUD) treatment programs vary in terms of tobacco-related policies and cessation services offered. Implementation of tobacco-related policies within this setting can face several barriers. Little is known about how program leadership anticipate such barriers at the pre-implementation phase. This study used the Consolidated Framework for Implementation Research (CFIR) during the pre-implementation stage to identify factors that may influence the implementation stage of tobacco-related cessation policies and services in residential SUD programs.

METHODS

We conducted semi-structured qualitative interviews with sixteen residential treatment program directors in California. The analysis was guided by a deductive approach using CFIR domains and constructs to develop codes and identify themes. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts.

FINDINGS

Themes that arose as anticipated facilitators for implementation included the relative advantage of the intervention vs. current practice, external policies/incentives to support tobacco-related policy, program directors' strong commitment and high self-efficacy to incorporate cessation into SUD treatment, and recognizing the importance of planning and engaging opinion leaders. Potential barriers included the SUD recovery culture, low stakeholder engagement, organizational culture, lack of workforce expertise, and lack of reimbursement for smoking cessation services.

CONCLUSION

To support successful implementation of tobacco-related organizational change interventions, staff and clients of residential SUD programs require extensive education about the effectiveness of evidence-based medications and behavioral therapies for treating tobacco dependence. Publicly funded SUD treatment programs should receive support to address tobacco dependence among their clients through expanded reimbursement for tobacco cessation services.

Tobacco use among substance use disorder (SUD) treatment staff is associated with tobacco-related services received by clients

BACKGROUND

Despite disproportionately high rates of smoking among people in residential substance use disorder (SUD) treatment, few receive tobacco cessation services. Little is known about how smoking among treatment staff may impact this disparity. We explored the relationship between staff tobacco use and client tobacco use. Additionally, we examined the relationship between staff tobacco use and tobacco-related services reported by staff and clients.

METHODS

Staff (n = 363) and clients (n = 639) in 24 California publicly-funded residential SUD treatment programs were surveyed in 2019-20. Staff self-reported current tobacco use, as well as their beliefs, self-efficacy, and practices regarding smoking cessation. Clients reported their tobacco use and they services received while in treatment. Regression analyses examined the adjusted and unadjusted associations between staff and client tobacco use and other outcomes.

RESULTS

Use of any tobacco product by staff ranged from 0% to 100% by program, with an average of 32% across programs. Adjusted analyses found that higher rates of staff tobacco use were associated with higher rates of client tobacco use, and with fewer clients receiving tobacco-related counseling. In programs that had higher rates of staff tobacco use, staff were less likely to believe that clients should quit smoking in treatment and had lower self-efficacy to address smoking.

CONCLUSION

Higher rates of tobacco use among staff are associated with higher rates of client tobacco use and fewer clients receiving cessation counseling. Efforts to reduce tobacco use among SUD clients should be supported by efforts to reduce tobacco use among staff. SUD treatment programs, and agencies that fund and regulate those programs, should aim to reduce the use of tobacco products among staff.

Racial/Ethnic Differences in Tobacco Use and Cessation Services among Individuals in Substance Use Treatment

Few studies explore racial/ethnic disparities in tobacco use and access to cessation services among people with substance use disorders (SUD). We collected data from Hispanics (n = 255), non-Hispanic Whites (n = 195), and non-Hispanic Blacks (n = 126) across 24 Californian residential SUD treatment programs. Data were analyzed via regression models adjusting for demographics, cigarettes per day, past quit attempts, intent to quit in the next 30 days, and physical health status. Non-Hispanic Whites smoked at a higher rate (68.7%) than both Hispanics (54.9%) and non-Hispanic Blacks (55.6%) and smoked more cigarettes per day (M = 11.2, SD = 6.5). Hispanics were more likely than non-Hispanic Whites to receive a referral to a cessation specialist (adjusted odds ratio; AOR = 2.34, 95% CI = 1.15, 4.78) and tobacco-cessation counseling (AOR = 2.68, 95% CI = 1.28, 5.62). Non-Hispanic Blacks were also more likely than non-Hispanic Whites to receive cessation counseling (AOR = 3.61, 95% CI = 1.01, 12.87) and NRT/pharmacotherapy (AOR = 2.65, 95% CI = 1.57, 4.47). Despite their decreased smoking prevalence and severity, REMs were accessing smoking cessation services while in treatment, suggesting that SUD treatment could serve as a place to address tobacco-related racial inequities.

Organizational Factors Moderating Changes in Tobacco Use Dependence Care Delivery Following a Comprehensive Tobacco-Free Workplace Intervention in Non-Profit Substance Use Treatment Centers

Although tobacco use is the leading preventable cause of death and is elevated among patients with substance use disorders, many substance use treatment centers (SUTCs) do not offer tobacco use interventions (i.e., screening and treatment). This study examined a key outcome of the implementation of a tobacco-free workplace program that provided education and specialized training to employees; namely, changes in clinician provision of the five As (Asking about tobacco use; Advising to quit; Assessing willingness to quit; Assisting with quitting; Arranging follow-up) from before to after the larger program implementation. The five As are a brief tobacco screening and treatment protocol that was taught as part of the program and that formed the basis for further intervention (e.g., provision of nicotine replacement therapies, Motivational Interviewing to enhance desire and willingness to make a quit attempt). Moreover, we also examined organizational moderators that may have impacted changes in the delivery of the five As over time among clinicians from 15 participating SUTCs. The number of the centers' total and unique annual patient visits; full-time employees; and organizational readiness for implementing change were assessed as potential moderators of change in clinicians' behaviors over time. Clinicians completed pre- and post-program implementation surveys assessing their provision of the five As. Results demonstrated significant increases in Asking (p = 0.0036), Advising (p = 0.0176), Assisting (p < 0.0001), and Arranging (p < 0.0001). SUTCs with higher Change Efficacy (p = 0.025) and lower Resource Availability (p = 0.019) had greater increases in Asking. SUTCs with lower Resource Availability had greater increases in Assessing (p = 0.010). These results help guide tobacco control program implementation to increase the provision of tobacco use interventions (i.e., the five As) to SUTC patients and elucidate Change Efficacy and Resource Availability as organizational factors promoting this clinician behavior change.

Factors associated with dual and polytobacco use among people in residential substance use disorder treatment

BACKGROUND AND OBJECTIVES

Little is known about whether people in substance use disorder (SUD) treatment are at risk for multiple-tobacco use. We examined the factors associated with dual- and polytobacco use among clients in SUD treatment.

METHODS

A cross-sectional survey was conducted in 2019 among 562 clients (M_age  = 39, 74% male) in 20 residential SUD treatment programs in California, USA. The outcomes included single-, dual- (use of two products), and polytobacco use (use of three of more products). Independent variables were nicotine dependence, quitting-related factors, blunt/spliff use, and health-related factors. A multinomial model examined associations between the independent variables and the outcome, controlling for demographics, and time in treatment.

RESULTS

Overall, 32.6%, 18.9%, and 14.0% of the sample were single-, dual-, and polytobacco users, respectively. Factors associated with increased odds of polytobacco use included greater nicotine dependence (adjusted odds ratio [AOR] = 1.60; 95% CI = 1.19, 2.16), ever using e-cigarettes for quitting (AOR = 4.56; 95% CI = 2.23, 9.34), and past 30-day use of blunt/spliff (AOR = 2.96; 95% CI = 1.48, 5.89). Factors associated with increased odds of dual use were ever using e-cigarettes for quitting (AOR = 3.19; 95% CI = 1.79, 5.66) and reporting more mentally unhealthy days (AOR = 1.05; 95% CI = 1.02, 1.07).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This study extends the literature on tobacco use among people in SUD treatment by revealing the high prevalence of dual- and polytobacco use and the unique characteristics of users. The findings have implications for interventions reducing all types of tobacco use in this understudied population.

COVID-19 vaccine trust among clients in a sample of California residential substance use treatment programs

BACKGROUND

Individuals with a substance use disorder (SUD) are at a significantly higher risk for coronavirus disease-19 (COVID-19) and have higher rates of COVID-19 related hospitalization and death than those without SUD. This study assessed COVID-19 vaccine trust, transmission awareness, risk and protective behaviors, and effects of COVID-19 on mental health and smoking among a sample of clients in California residential SUD treatment programs and identified factors associated with vaccine trust.

METHODS

A multi-site sample of SUD treatment clients (n = 265) completed a cross-sectional survey. Multivariable logistic regression was used to identify factors associated with COVID-19 vaccine trust.

RESULTS

Participants were predominantly male (82.3 %) and racially/ethnically diverse (33.3 % Non-Hispanic White). Most participants were aware of COVID-19 modes of transmission, however, only 39.5 % trusted a COVID-19 vaccine would be safe and effective. Factors independently associated with trust in a COVID-19 vaccine included age (AOR = 1.03, 95 % CI = 1.02, 1.05, p = 0.0001) and wearing a mask all the time (AOR = 2.48, 95 % CI = 1.86, 3.31, p = 0.0001). African Americans were less likely than White participants to trust that a COVID-19 vaccine is safe and effective (AOR = 0.41, 95 % CI = 0.23, 0.70, p = 0.001).

CONCLUSION

SUD treatment clients were aware of COVID-19 modes of transmission; however, fewer than half trusted that a COVID-19 vaccine would be safe and effective. Health communication about COVID-19 for people with SUD should use a multipronged approach to address COVID-19 vaccine mistrust and transmission risk behaviors.

Correlates of e-cigarette use for smoking cessation among clients in residential substance use disorder treatment

Little is known about e-cigarette use among persons in substance use disorder (SUD) treatment, or their use of e-cigarettes for smoking cessation. Prevalence of e-cigarette use and correlates of e-cigarette use for smoking cessation were examined among clients in SUD treatment. Participants (n = 332) were current cigarette smokers recruited from 20 residential SUD programs in California. We used multivariable logistic regression to identify correlates of using e-cigarettes for quitting smoking. Almost half (45.2%) of the sample had ever used e-cigarettes for smoking cessation, and 34% had used e-cigarettes in the past 30 days. Smokers who had used e-cigarettes for smoking cessation, compared to those who had not, were younger (adjusted odds ratio [AOR] = 0.94, 95% confidence interval [CI] = 0.91, 0.96), had more than a high school education (AOR = 1.69, 95% CI = 1.07, 2.68), sought treatment for both SUD and mental health disorder (AOR = 2.62, 95% CI = 1.38, 5.00), wanted help quitting smoking (AOR = 1.90, 95% CI = 1.03, 3.50) and perceived e-cigarettes as equally harmful (AOR = 3.03, 95% CI = 1.10, 8.33) or less harmful than tobacco cigarettes (AOR = 2.82, 95% CI = 1.02, 7.77). Black/African American and Hispanic/Latino participants were less likely to use e-cigarettes for smoking cessation than participants who identify as White. E-cigarettes were favorably perceived by clients in residential SUD treatment as a quit smoking aid. Treatment programs should consider how to advise clients with respect to the use of e-cigarettes for smoking cessation.

Organizational-Level Moderators Impacting Tobacco-Related Knowledge Change after Tobacco Education Training in Substance Use Treatment Centers

Tobacco use is disproportionately elevated among patients with substance use disorders relative to the general U.S. population. Tobacco interventions are lacking within substance use treatment centers (SUTCs) due to lack of knowledge and training. This study examined knowledge gain and the organizational factors that might moderate knowledge gains following tobacco education training provided to employees (N = 580) within 15 SUTCs that were participating in a tobacco-free workplace program. The number of total annual patient visits, unique annual patient visits, number of full-time employees, and organizational readiness for implementing change (ORIC) as assessed prior to implementation were examined as potential moderators. Results demonstrated significant knowledge gain (p < 0.001) after training overall; individually, 13 SUTCs had significant knowledge gain (p's < 0.014). SUTCs with fewer total annual patient visits and fewer full-time employees showed greater knowledge gains. The ORIC total score and all but one of its subscales (Resource Availability) moderated knowledge gain. SUTCs with greater initial Change Efficacy (p = 0.029), Valence (p = 0.027), and Commitment (p < 0.001) had greater knowledge gain than SUTCs with lower scores on these constructs; SUTCs with greater Task Knowledge (p < 0.001) regarding requirements for change exhibited less knowledge gain. Understanding the organizational-level factors impacting training effectiveness can inform efforts in organizational change and tobacco control program implementation.

Impacts of COVID-19 on residential treatment programs for substance use disorder

INTRODUCTION

The COVID-19 pandemic may present special challenges for residential substance use disorder (SUD) treatment facilities, which may lack infrastructure and support to implement infection control protocols while maintaining on-site treatment services. However, little is known about how residential SUD treatment programs are impacted by the COVID-19 pandemic.

METHODS

The research team conducted semi-structured interviews with 17 directors of 20 residential SUD treatment programs across California during the state's shelter-in-place order. The researchers then analyzed qualitative interview data thematically and coded them using ATLAS.ti software.

FINDINGS

Thematic analyses identified six major themes: program-level impacts, staff impacts, client impacts, use of telehealth, program needs, and positive effects. "Program-level impacts" were decreased revenue from diminished client censuses and insufficient resources to implement infection control measures. "Staff impacts" included layoffs, furloughs, and increased physical and emotional fatigue. "Client impacts" were delayed treatment initiation; receipt of fewer services while in treatment; lower retention; and economic and psychosocial barriers to community re-entry. "Use of telehealth" included technical and interpersonal challenges associated with telehealth visits. "Program needs" were personal protective equipment (PPE), stimulus funding, hazard pay, and consistent public health guidance. "Positive effects" of the pandemic response included increased attention to hygiene and health, telehealth expansion, operational improvements, and official recognition of SUD treatment as an essential health care service.

CONCLUSION

Study findings highlight COVID-related threats to the survival of residential SUD treatment programs; retention of the SUD treatment workforce; and clients' SUD treatment outcomes. These findings also identify opportunities to improve SUD service delivery and suggest avenues of support for residential SUD treatment facilities during and after the COVID-19 pandemic.